Post-Acute Care

Working together to prevent patient decline, ensure positive care transitions, and provide quality, evidence-based care to all patients

The Millennium Post-Acute Care Team is working in the Skilled Nursing and Home Care Settings to help lower the rates of hospital readmissions of patients and residents. Together we will be able to achieve 25 percent reduction in avoidable emergency room visits and hospitalizations.

Facilitating best practices to enhance the patient follow up care after emergency room treatment

The INTERACT Program seeks to decrease rates of hospitalization among Post-Acute patients.

We Are Creating Change…

The Post-Acute Care Team is implementing the following strategies within Skilled Nursing Facilities and Certified Home Health Agencies:

Early identification and evaluation of patient symptoms in order to prevent further patient decline and potential hospital admission.

“Treat in place” philosophy, caring for patients in house whenever appropriate.

Advance care planning and the use of palliative care plans through facilitated end of life conversation with patients, family, and the care team. Generation of meaningful, values-based Advanced Directives and care plans to direct future care decisions.

Improve communication and documentation internally within Skilled Nursing Facilities and Home Care Agencies. Utilization of communication protocols and reporting standards to ensure information flow is moving between disciplines in each setting.

Enhance discharge planning across and procedure which is culturally competent, taking into account social determinants of health barriers and patient health literacy. Incorporation of community based organizations and supports to further assist in stabilizing and maintaining good health of patient.

Advanced Care Planning and Palliative Care Committee

The objective of the Advanced Care Planning and Palliative Care Committee is to identify the issues of End-of-Life planning such as patient and provider engagement, and Advanced Directive completion for the patients. Another focus is increasing staff, patient, and family knowledge about End-of-Life issues encouraging conversations to coordinate better care for their loved ones.

Upcoming

Resources

Partners

Igniting Healthcare Change in WNY

Millennium Collaborative Care, a Performing Provider System (PPS), is igniting healthcare change by partnering with physicians, healthcare providers and community-based organizations to improve the delivery of healthcare for Medicaid patients across the eight counties of Western New York.